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Vargas HD. Gaining Mesenteric Length following Colorectal Resection: Essential Maneuvers to Avoid Anastomotic Tension. Clin Colon Rectal Surg 2023; 36:37-46. [PMID: 36643828 PMCID: PMC9839430 DOI: 10.1055/s-0042-1758776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A surgeon must possess the knowledge and technical skill to obtain length following a left-sided colorectal resection to perform a tension free anastomosis. The distal target organ - either rectum or anus - is fixed in location, and therefore requires surgeons to acquire mastery of proximal mobilization of the colonic conduit. Generally, splenic flexure mobilization (SFM) provides adequate length. Surgeons benefit from clearer understanding of the multiple steps involved in SFM as a result of improved visualization and demonstration of the relevant anatomy - adjacent organs and the attachments, embryologic planes, and mesenteric structures. Much may be attributed to laparoscopic and robotic platforms which provided improved exposure and as a result, development or refinement of novel approaches for SFM with potential advantages. Complete mobilization draws upon the sum or combination of the varied approaches to accomplish the goal. However, in the situation where extended resection is necessary or in the case of re-operative surgery sacrificing either more proximal or distal large intestine often occurs, the transverse colon or even the ascending colon represents the proximal conduit for anastomosis. This challenging situation requires familiarity with special maneuvers to achieve colorectal or coloanal anastomosis using these more proximal conduits. In such instances, operative techniques such as either ileal mesenteric window with retroileal anastomosis or de-rotation of the right colon (Deloyer's procedure) enable the intestinal surgeon to construct such anastomoses and thereby avoid stoma creation or loss of additional large intestine.
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Affiliation(s)
- Herschel David Vargas
- Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
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Carpinteyro-Espín P, Santes O, Moctezuma-Velazquez P, Navarro-Iñiguez JA, Navarro-Navarro A, Salgado-Nesme N. Deloyers procedure compared to ileorectal anastomosis as restoration techniques of bowel continuity after extended left colon resection. ANZ J Surg 2022; 93:956-962. [PMID: 36196846 DOI: 10.1111/ans.18084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/14/2022] [Accepted: 09/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Restoration of bowel continuity after left extended colectomy may be challenging because the remaining colon may not reach the rectal stump without tension to perform a safe anastomosis. Performing a total colectomy with ileorectal anastomosis (IRA) is an option, but the quality of life can be significantly impaired due to loose stools and an increase in bowel frequency. In contrast, the preservation of the right colon and ileocaecal valve in the Deloyers procedure (DP) might ensure a better stool consistency and bowel transit, and therefore a superior quality of life. MATERIALS AND METHODS A transverse study comparing patients that underwent DP versus patients with an IRA was performed. Postoperative morbidity, mortality, functional outcomes, and quality of life were analysed between groups. Quality of life after the surgical procedure was assessed with the SF-36 V2® health survey. RESULTS A total of 16 patients with DP and 32 with IRA were included. The groups had similar demographic characteristics concerning age, sex, body mass index, ASA classification, diagnosis and Charlson comorbidity index. The median follow-up was 55 months for DP and 99 months for IRA. Postoperative complications were similar in both groups. Patients in the DP group had fewer bowel movements (P = 0.01), tenesmus (P = 0.04) and use of loperamide (P = 0.03). DP patients achieved better scores in physical pain (P = 0.02) and general health (P < 0.01) than IRA patients. CONCLUSIONS DP for intestinal continuity restoration after extended left colon resection is a safe and feasible alternative, possibly achieving better functional outcomes and quality-of-life compared to IRA.
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Affiliation(s)
- Paulina Carpinteyro-Espín
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Oscar Santes
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Paulina Moctezuma-Velazquez
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Julio A Navarro-Iñiguez
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Adolfo Navarro-Navarro
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Noel Salgado-Nesme
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Surgical Techniques and Outcomes of Colorectal Anastomosis after Left Hemicolectomy with Low Anterior Rectal Resection for Advanced Ovarian Cancer. Cancers (Basel) 2021; 13:cancers13164248. [PMID: 34439401 PMCID: PMC8393927 DOI: 10.3390/cancers13164248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/12/2021] [Accepted: 08/20/2021] [Indexed: 11/17/2022] Open
Abstract
Extended colon resection is often performed in advanced ovarian cancer. Restoring intestinal continuity and avoiding stoma creation improve patients' quality of life postoperatively. We tried to minimize the number of anastomoses, restore intestinal continuity, and avoid stoma creation for 295 patients with stage III/IV ovarian cancer who underwent low anterior rectal resection (LAR) with or without colon resection during cytoreductive surgery. When the remaining colon could not reach the rectal stump after left hemicolectomy with LAR, we used the following techniques for tension-free anastomosis: right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, or an additional colic artery division. Rates of stoma creation and rectal anastomotic were 3% (9/295) and 6.6% (19/286), respectively. Among 21 patients in whom the remaining colon did not reach the rectal stump after left hemicolectomy with LAR, 20 underwent tension-free anastomosis, including eight, six, and six patients undergoing right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, and an additional colic artery division, respectively. Colorectal anastomosis is feasible for patients with extended colonic resection. Low anastomotic leakage and stoma rates can be achieved with careful attention to colonic mobilization and tension-free anastomosis.
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Zhang X, Yang L, Tang ST, Cao GQ, Li S, Jiang M, Xiong M, Yang DH, Chang XP, Li K, Ma YZ. Laparoscopic Duhamel Procedure with Ex-Anal Rectal Transection for Right-Sided Hirschsprung's Disease. J Laparoendosc Adv Surg Tech A 2017; 27:972-978. [PMID: 28737964 DOI: 10.1089/lap.2016.0469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Increased defecation frequency and soiling are common complications of surgery for right-sided Hirschsprung's disease (HD). Though the laparoscopic Duhamel procedure is a favorable option in right-sided HD, the conventional laparoscopic technique is time consuming and has complications that are associated with the reservoir. In this study, we described a modified laparoscopic Duhamel technique with ex-anal rectal transection combined with the Deloyer's procedure for right-sided HD. MATERIALS AND METHODS Between March 2010 and January 2015, 18 right-sided HD underwent this modified laparoscopic Duhamel procedure (MLDP). The main modifications were to mobilize the colon and to dissect the retrorectal space under laparoscopy, pull out, and transect ex-anally by using a linear stapling device through a transverse incision on posterior wall of the rectum. Seven age-matched patients who underwent a conventional laparoscopic Duhamel procedure (CLDP) between March 2008 and December 2010 were included as the control group. Demographics, surgical procedures, operative data, postoperative complications, and clinical outcomes were compared between these two groups. RESULTS Operative time was significantly shorter in the MLDP group (150 minutes versus 195 minutes; P = .03). There was no significant difference in mean timespan to obtain a normal defecation frequency (3.8 months versus 3.6 months), incidence of soiling (11.1% versus 14.3%; P = .34), and constipation (5.6% versus 14.3%; P = .69). Pouchitis were not found in the MLDP group, whereas 2 patients in the CLDP group (28.6%) presented with pouchitis and intractable diarrhea, requiring spur division. The incidence of postoperative enterocolitis was not significantly different in the two groups (11.1% in MLDP versus 14.3% in CLDP; P = .68). All 22 patients had a normal defecation over 4 years of age. CONCLUSIONS Laparoscopic Duhamel with ex-anal rectal transection is a simple, easy-to-learn, and effective procedure for right-sided HD. It has low postoperative pouchitis because of a short pouch.
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Affiliation(s)
- Xi Zhang
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Li Yang
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Shao-Tao Tang
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Guo-Qing Cao
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Shuai Li
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Meng Jiang
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Meng Xiong
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - De-Hua Yang
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Xiao-Pan Chang
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Kang Li
- 1 Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China
| | - Ya-Zhen Ma
- 2 Department of Pediatric Surgery, The Second Hospital of Hebei Medical University , Shijiazhuang, China
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Antona AD, Reggio S, Pirozzi F, Corcione F. Laparoscopic 3D high-definition Deloyers procedure: when, how, why? Updates Surg 2016; 68:111-3. [PMID: 27062142 DOI: 10.1007/s13304-016-0355-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/22/2016] [Indexed: 01/16/2023]
Abstract
After extensive mobilization and resection of the left colon, colorectal anastomosis may result impossible due to the distance between the remaining colon and the rectal stump. The Deloyers procedure represents an interesting alternative to total colectomy with ileorectal anastomosis. In this manuscript, we describe when and how to perform this technique with a mini-invasive approach. We also report the case of a patient who underwent Deloyers procedure, due to early ischemia of the descending colon after left colectomy.
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Affiliation(s)
- Angelo Danilo Antona
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli", Monaldi Hospital, Via Leonardo Bianchi, 80131, Naples, NA, Italy
| | - Stefano Reggio
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli", Monaldi Hospital, Via Leonardo Bianchi, 80131, Naples, NA, Italy
| | - Felice Pirozzi
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli", Monaldi Hospital, Via Leonardo Bianchi, 80131, Naples, NA, Italy.
| | - Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, "Azienda Ospedaliera dei Colli", Monaldi Hospital, Via Leonardo Bianchi, 80131, Naples, NA, Italy
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Retroileal colorectal anastomosis after extended left colectomy: application for laparoscopic surgery. Surg Today 2016; 46:1476-1478. [DOI: 10.1007/s00595-016-1313-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/05/2016] [Indexed: 12/13/2022]
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Dumont F, Da Re C, Goéré D, Honoré C, Elias D. Options and outcome for reconstruction after extended left hemicolectomy. Colorectal Dis 2013; 15:747-54. [PMID: 23398679 DOI: 10.1111/codi.12136] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 10/13/2012] [Indexed: 01/02/2023]
Abstract
AIM A tension-free anastomosis is required to minimize anastomotic leakage after an extended left colectomy when the residual transverse colon is too short to spontaneously reach the pelvis. To resolve this problem, colonic rotation with a right colonic transposition (RCT) or even with a complete intestinal derotation (CID) is mandatory. This study compared these two techniques. METHOD Between January 2001 and December 2011, 39 patients had undergone right colonic transposition (n = 29) or complete intestinal derotation (n = 10) after an extended left colectomy. All anastomotic complications had been recorded during the follow up. RESULTS No differences were found between right colonic transposition and complete intestinal derotation in terms of patient characteristics, surgical indications, therapeutic features and risk factors for anastomotic leakage (sex, American Society of Anesthesiology (ASA) score, diabetes, bevacizumab use, colorectal anastomotic level or protective stoma use). Ligature of the middle colic artery was significantly more frequent with right colonic transposition than with complete intestinal derotation (82.7% vs 50%; P = 0.04). An additional colonic resection tended to be required more often in the right colonic transposition group than in the complete intestinal derotation group (55.1% vs 20%; P = 0.054). The anastomotic complication rate was 10.2% and was not significantly different between right colonic transposition and complete intestinal derotation (6.9% vs 20%, P = 0.24). CONCLUSION Both colonic rotation techniques are feasible and safe. The right colonic transposition and complete intestinal derotation techniques yielded similar results in terms of colorectal anastomotic complications, but right colonic transposition required ligature of the middle colic artery and additional colonic resection tended to be required more frequently.
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Affiliation(s)
- F Dumont
- Department of Digestive Oncological Surgery, Institut Gustave Roussy, Villejuif, France.
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